Basic Information
| Provider Information | |||||||||
| NPI: | 1669642260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAUCKMAN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | THOMA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6000 BOND AVE | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622072328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183322083 | ||||||||
| FaxNumber: | 6183376039 | ||||||||
| Practice Location | |||||||||
| Address1: | 6000 BOND AVE | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622072328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183322083 | ||||||||
| FaxNumber: | 6183376039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 209007010 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.